These letters
concern difficult and/or confusing therapeutic issues between clients
and clinicians. They were originally posted to my advice forum,
and I hope they'll be useful to you.

*~*~*~*~*~*~*~*

Q.
I'm in private practice. My client got angry, wrote her check
and stormed out of our session. I'm not sure how to handle this.
Advise, please?

A.
Are you familiar with personality disorders? Has it been your sense
that this client runs 'hot and cold' with you during the
time you've treated her? Anything may have triggered this response,
as you might have unwittingly stepped on an old (emotional) land
mine from her childhood. Whether she's borderline
disordered or not, it's critical you attempt to make amends.
Call and leave a voicemail with a sincere, heartfelt apology for
having upset her (even though you may have no clue about how it
happened). Take ownership of the rupture, and invite her to come
back and talk with you about it. Be extra-sensitive and empathic
to how this session made her feel, if/when she agrees to
speak with you. Therapeutic ruptures can deepen a client's trust
in you, if handled sensitively. If she doesn't respond or return,
send a follow-up note with referrals to several other therapists,
and wish her well.

A.
Generally, no. But a professional won't do this, unless you've consistently
demonstrated an inability or unwillingness to be compliant with
treatment. If you've utilized his/her guidance and suggestions,
there's no reason to end a therapeutic alliance--but if you haven't,
and you're struggling with the same issues after a reasonable time
frame (three to six months), then they have every right to determine
that you will not benefit from continuing with them, and should
refer you out to someone else.

Q.
I'm a psychotherapist, and I'm on burn-out. At times, I wonder
why I'm even in this business--even though I love my work. How do
I get past this?

A.
This is a common complaint I've heard for many years, and
here's a multi-layered answer: First, if treating people is the
only way you have of deriving a sense
of accomplishment, you are in the
"wrong business." Avocations or hobbies are essential
for anyone in the helping/healing professions. This will give your
life more balance--and enhance self-worth (because clients don't
improve all that fast). Accept that you have other talents and abilities
that want to be recognized and fed, discover what they are, and
make time for them! These might involve activities or creative outlets
from childhood that provided joy or satisfaction back then,
but you abandoned later on. Making your own life richer
and fuller will help you become a better therapist; you'll have
more resources to bring to the party. Borderlines
and Narcissists
can be very difficult/demanding clients, as they're resistant to
change or growth. If you have clients with these personality disorders
in your practice, you're more likely to experience frequent burn-out.
In either case, cerebral/spiritual energy expenditure of this type,
means you must recharge your batteries on a fairly regular
basis. Hang out with friends, watch too much TV, or sleep for a
day or two. You'll feel brand new again.

Q.
My sister's boyfriend is a psychotherapist in private practice.
He recently announced to our family that he'd started treating a
well known actor, and revealed the name of this person. Something
inside me felt this was wrong, but I was reluctant to say anything
at the time. Should he have done this? Should I have shared my feelings
that this wasn't right? Disappointed.

A.
Your feelings about this are very valid and astute. Many
years ago when I'd first returned to school, an almost identical
situation happened to me. I'd had the same feelings about it as
you did, and felt that this must represent an ethical
breach. My schooling much later confirmed theseintuitions.
Some of my colleagues share this kind of news among themselves,
when they're treating someone with celebrity status--but revealing
the identity
of a client is absolutelywrong,
regardless of who you're talking to. I've chalked these behaviors
up to developmental deficits, poor boundaries/impulse control and
an 'undercooked' ego or sense of Self; yes, borderline traits and
narcissism are
fairly common within this community. It's appropriate to tell your
sister's boyfriend, that sharing the identity of a client made you
feel uncomfortable, and undermined your trust.

Q.
For the past couple of years, I've been seeing a wonderful therapist
who has helped me a lot. I feel like I'm ready to try it on my own
for awhile, but I don't know how to approach this awkward topic
with her. Any advice?

A.
Why don't you think about saying just
that? Most clinicians don't want to keep you in treatment, if you
don't want to be there--even when they feel there's more work to
be done (because you'll be acting-out these feelings, rather
than communicating them). Given that you're having difficulty finding
your voice and approaching this dialogue in a straightforward, adult
manner, maybe you're not quite ready to fly solo.

Q.
Shari, can a therapist date their client after treatment has
ended?

A.
Not unless he or she wants tolose their license
to practice. A mandatory two year waiting
period must be observed once therapy has ended, before a psychotherapist
and client may become involved. Most BBS regulations are for the
protection of the client/patient; this one's critical for the well-being
of both parties. Clinicians who don't play by these rules
can face disasterous outcomes professionally
and personally. Therapeutic relationships seldom transition
into balanced, healthy partnerships, because the established roles
have to change. Both parties must adapt to an interdependent
dynamic, and that's usually a tough adjustment. BBS is the Board
of Behavioral Sciences.

Q.
I ended a three year stint in therapy a couple months back,
because I was pissed-off at my doctor. I sent him a letter telling
him off, and stated that I wasn't going to be returning. I'm regretting
this, as some issues have come up that I'm needing help with. I
suppose I wanted to burn that bridge when I left, so contacting
him now feels pretty awkward, and I'm afraid he
won't be open to seeing me again. What should I do?

A.
In my view, a solid therapist anticipates your anger as
part of the healing process in treatment--and leaves his/her door
open, should you ever want or need to return. Sadly, many individuals
harshly judge their own anger, which makes it impossible to imagine
that anyone else can accommodate it. These people typically
abandon their relationships, rather than staying to resolve
conflicts. This pattern
was learned in childhood, when they had to suppress difficult feelings,
because expressing them usually meant punishment, guilt
or shame. Leave a brief message for your therapist, asking if you
can make an appointment. He'll likely respond affirmatively--but
if not, find somebody else to assist you.

Q.
I'd like to give my therapist a gift, but I don't know if it's
appropriate. He's given me extra time when I've needed it, and not
charged me--so this is a kind of 'thank you' gesture. Any thoughts?

A.
A one-time gesture of gratitude is fine--but how it's received,
depends on the therapist. Regardless of psychotherapeutic guidelines
discouraging this sort of practice, some clinicians readily accept
gifts from patients (and give them as well). Rules and guidelines
are designed to protect the client. I've been known to
take a hard line in relation to this topic, as treatment can be
contaminated by it. As an example, if gift-giving has become a standard
in this relationship, what happens when someone leaves therapy?
Should gift exchange continue indefinitely--and what interpretations/feelings
will clients struggle with, if/when it doesn't? In my opinion, this
complex issue muddies therapeutic waters, and should be avoided.
Recommending someone to your therapist can demonstrate appreciation--aside
from this, an impersonal gift (a plant, for instance) is best.
(More on this topic can be found below.)

Q.
Hello Shari, my partner and I decided to look for a therapist about
a year ago. I had difficulty finding one within my small community,
as it seems there's an incestuous trend among gay women knowing
one another, and the therapists themselves often belong to that
circle. My partner was consumed with wanting to go to a lesbian
therapist. I wanted to remain open, so I agreed. We went to two
sessions together--and upon completion of the second one, the therapist
handed me information for group meetings in my area, and told my
partner to continue (with her) alone. Two sessions,
and this woman tells my partner that we have a love-addicted relationship,
and she needs to run away from me as fast as she can! I was crushed.
It's my understanding that even after multiple sessions, it's never
a therapist's place to tell a client what to do, and I was angry--as
after a total of only 2 meetings, she'd come to that conclusion.
My partner had a lot of confusion in her life, and I feel she was
easily swayed. Now, months after this first happened, she has it
in the back of her mind that I have too many issues, and we are
bad for each other. I know I have work to do, and I know my partner
has her work. I believe that in relationship, each does their work,
while coming (closer) together. I realize that time heals all. I
guess I'm asking for some confirmation or support to keep us moving
forward, while I try to keep this therapist's actions from haunting
me each time my partner buys another book about love addiction.
I'm an advocate of self help books--however without the proper direction
(and I don't think two sessions allow for this), my partner keeps
bringing up any symptoms she thinks apply to us, which may not have
been there before they were suggested. Thanks for taking the time
for me.

A.
The two of you saw this therapist with the specific intention of
helping your relationship--and in conjoint work, the
couple is the client. It appears this woman has failed
to respond to your desire for couples work, and her assessments
and subsequent actions seem premature. A couples therapist cannot
guarantee that the bond between two people will become
stronger. Over time, his/her job might be to help them define and
come to terms with irreconcilable differences, and separate
in a manner that's as harmonious as possible. Responsible clinicians
apprise you of this potential within the first session,
but attempt to help you diffuse and resolve conflict. Solid conjoint
therapy teaches couples verbal and listening skills, uncovers and
explores background issues that have contributed to the difficulties,
and encourages genuine empathy based on these insights. Time doesn't
necessarily heal all, and it isn't designed to--but competent,
unbiased support can go a long way toward helping a relationship
heal.

Q.
I've been needing some help to deal with a relationship crisis.
I've left my phone number and message at various therapists' offices
for the past couple of weeks--but nobody's gotten back to me! I'm
wondering how long it should it take for a professional to call
me back, and is this sort of delay usual or standard practice?

A.
This is definitely not considered standard practice.
A responsible clinician will return your call within
24 hours--even if he/she just needs to arrange a more convenient
time to speak with you, and assess whether (or not) they can provide
solid help with your immediate struggle. The only exception to this,
would be if the therapist is on vacation, or some type of necessary
leave from their practice--but this should always
be indicated in their outgoing voicemail. Frankly, I've heard similar
reports from quite a few people, and it's utterly astounding
to me that this kind of thing even happens! Perhaps
the only saving grace in all this, is that you're somehow being
protected from engaging assistance from people who are (obviously)
incapable of responding to your needs.

Q.
Shari, one of my clients persists in giving me gifts. We've
explored the meaning of these gestures (therapeutically), and I've
strongly discouraged this practice, but he keeps showing up with
"little things" he thinks I'll accept, and I'm not sure
what to do about it. Any ideas?

A.
Clinicians seem pretty divided on this issue, regardless of established
psychotherapeutic guidelines that strongly discourage it. Aside
from wanting to convey affection, there could be myriad reasons
why your client is maintaining this behavior despite your
interventions, and here are several possibilities: 1.
On some level, he needs to control the therapeutic dynamic, and
thinks this will make you like him more. 2. He
could have issues with entitlement, which make it difficult for
him to receive from you, without feeling guilty and obliged
to reciprocate (and your fee might be too low). 3.
He may not have been able to develop object constancy
in infancy, so he's unable to hold/maintain a sense of you and this
connection, in-between sessions. This can derail his ability to
trust that you care about or consider his needs
when he's away from you, and drives a powerful urge to leave tokens
(of himself), which he hopes will remindyou that
he exists. 4. He's never felt intrinsically
lovable, so the compulsion to giveyou things,
helps him feel moreworthy of your attention and care.
This compensatorybehavior is generally tied to a lack
of self-worth; continue your deeper work with him surrounding
this (core) issue, for it surely impacts his other relationships.
Graciously thank him for the gifts, but have him leave with them
at the end of sessions.

Q.
I phoned a trusted buddy a few nights ago, because I'm conflicted
about a woman I'm dating. His feedback was very helpful, but when
I told my therapist about this, she seemed upset
with me. She acted like I'd done something wrong, and I'm feeling
ashamed and afraid that she's mad at me. I'm really wondering if
I screwed up. Did I violate some sort of "therapy rule"
by calling my friend for help?

A.
Part of meaningful inner work involves some initial dependency on
your therapist, but solid therapeutic intervention
encourages reliable, supportive relationships in your interpersonal
world. It may be that yours somehow felt threatened by
this reliance on your friend's help. Given that you feel shamed
by her reaction and appear to be fearing her abandonment, she might
have borderline
personality features, which could have prompted a 'split' in
her perceptions of you (good client/bad client). You did nothing
wrong, and no "rule" was broken. Hold onto that friendship.

Q.
Shari, my therapist has recently gotten her state license (for
the past several months, she's been seeing me as an "intern").
The other day, she informed me that my fee ($40.00) would be doubling
in two weeks, as she's starting a private practice. There's been
a good connection with this woman and I don't want to leave, but
I can't afford to pay her $80.00 a week! She's very aware of my
financial situation, and I'm now feeling she doesn't even care.
I'm really bummed out about this, and angry! Is
it customary to force clients out, due to a change in professional
status?

A.
I think your anger is warranted. Your therapist is certainly
entitled to make business decisions in any way she pleases, but
that doesn't mean her methods are ethical or sensitive
to your needs. In my view, you're describing therapist
abandonment, which is damaging to you, and terribly unfair.
A standard fee increase is customarily no more than $10.00
per session, and should be anticipated after a full year
in ongoing treatment. The fact that she's "aware" of your
financial status and isn't willing to make allowances for this,
could be viewed as self-serving. I've always believed that healingprofessionals had a certain level of 'response-ability' to
their clients, and this sort of practice doesn't seem to fit under
that umbrella. I encourage you to share these sad/angry
feelings with your therapist over the next couple of weeks, and
see what comes of that. You may also state that you'd like to continue
working with her, if she'll consider a more gradual increase
in her fee scale. Given that she's just starting out, she'll likely
have room in her schedule and could agree to your request, but this
may be moot. If you feel your trust has
been undermined by her actions, it's understandable that you might
choose not to return.

Q.
I've been seeing my therapist for about 18 years and have grown
very fond of her, but feel it's time for me to move on. Over the
years when I've talked about leaving, she has strongly discouraged
this due to my "unresolved issues," and I'm concerned
that this time will be no different. I feel I owe
her a great deal; she's helped me get through some terrible
times with my ex-husband, guided me in raising my child, and assisted
me with many other issues. I almost feel like she's family. We exchange
presents during the holidays, and she never neglects to give me
something special for my birthday. I'm in a wonderful relationship
now, and I don't feel I need her nearly as much as I once did. I'm
afraid that my leaving therapy will hurt her, which makes me feel
guilty and ungrateful. This is hard, and I could really use some
guidance.

A.
It seems your therapist has fostered/promoted an enmeshed
relationship with you. Some keep their clients in treatment far
longer than necessary, to gratify a personal need
to be needed or bolster financial resources.
Along these lines, receiving presents from clients is strictly
discouraged by psycho-therapeutic guidelines; it blurs the boundaries
of a professional relationship, and contaminates the therapeutic
process. You pay this woman for her time and
expertise; in acceptingyourgifts, she lets
you infer that you may pay her (extra) to care
about you, and this undermines your progress on many levels! You
have fulfilled your obligation as a compliant participant in your
treatment, by showing up on time for your appointments, following
sound guidance and suggestions, and working hard to integrate any
insights gained while under her care. Anything she sanctions beyond
this, suggests a lack of ethical standards. Your trouble with "leaving,"indicates how acutely you've been affected by this, and surely
parallels childhood experiences that forced you to put other's needs
before your own; this tendency should have been dismantled
throughout this inner work, not exacerbated!Hopefully, you've moved into a maintenance schedule (fewer
visits per month) in recent years, which has helped you experience/exert
more emotional self-reliance. A solid professional
works with you in a manner that helps youtrust
that his/her door will remain open in the future, should you hit
a 'speed-bump' or crisis, and need to return. Say "thank you,
and goodbye" in anote or card if this is easier for
you at present, and get on with your Life.

Q.
Shari, I recently went to see a psychotherapist in my area who
was recommended by a friend. This woman asked a few questions about
me, and then proceeded to tell me (unsolicited) material aboutherself; how and why she got into this business,
her emotional background, etc. At first I felt confused about why
this was happening, and then became increasingly annoyed
that roughly 2/3's of my session time
was spent having to listen to her go on about herself! The way I
see it, I was paying a substantial fee for this visit, and while
I don't have another frame of reference (this is my first time in
therapy) I felt like this shouldn't be happening--especially
on MY dime! Basically, I feel like I flushed my $150.00
down the toilet. Is this kind of thing standard practice?
CB

A.
Dear CB, I applaud your instincts in sensing this wasn'tprofessional
behavior, and it appears this therapist's practices shouldcome under closer scrutiny (can you stop payment on
that check?). In my view, any clinician who neglects to respond
to your needs, and charges you for hearing him/her
talk about their issues, shouldn't be working in this field.
There be may instances during the course of ongoing treatment where
self-disclosure isappropriate, but this should be carefullyassessed by the therapist, as to how (and if)this
servesyouin
context of what you're working on at that time. Therapeutic professionals
should be willing to answer your questionsabout
their schooling, training/qualifications, but be extremelydiscretionary when it comes to sharing intimate/private
material, as he/she is being paid to assist You! The more personal
information you're aware of concerning your therapist, the more
responsibility you may assume for his/her frailties or needs. This
contaminates your therapeutic process, as it can
reconstitute and perpetuate childhood obstacles you had with a narcissistic
parent, derail your ability to be open and expressive with your
feelings or thoughts, and potentiate boundary issues between
you! Any of these outcomes inhibit your capacity to make solid progress.
Don't be afraid to state your position in a follow-up call or note.
Seems to me, you're entitled to a refund or (at least)
reimbursement for two-thirds of your "session"
fee.

Q.
I've gotta run something by you, Shari. I've been seeing a therapist
for a couple of months in relation to a difficult break-up with
my girlfriend. At first, this doctor seemed effective in helping
me with my feelings surrounding this loss, gaining insights about
myself, etc. But in the last few sessions, she's been dressing more
provocatively and making comments that feel suggestive. I've been
pretty revealing about the sexual aspects of my last relationship
(and others), and I'm now wondering if this was
wrong to do. While I'm flattered by her compliments and they help
me feel better about myself, I can't help sensing she's coming on
to me. I'd like to remain in therapy until I'm stronger and more
resolved about this recent crisis, but I'm starting to feel uncomfortable
with her. Maybe it's my imagination, but I think she's being seductive
with me, and it's distracting. I'm not sure what I should do.

A.
First of all, therapyNEVER includes
sex! Any psychotherapist who crosses this line is subject
to fines, imprisonment and revocation of his/her license to practice.
Your self-revelations are perfectly normal/natural within this context
(how else can a clinician learn about you, understand what
matters to you, and assist you?). Feeling like you've shared
something too personal can be a direct outcome of working
with someone who has undermined your trust. Whether
this woman is being inappropriate with you or not, your
feelings about this situation must be
honored. Are you able/willing to share these, as well as your observations
with her? Your therapist's handling of this material will give you
a sense of how to proceed: If she appears to take in what you've
said, and gently asks questions about how you've arrived
at these impressions and what they've meant to you, that's a good
start. If she confirms your suspicions or
reacts defensively to your words, invalidates your perceptions and/or
makes this about "your issues," leave
and find a professional who can work with you in a manner that's
healing as opposed to harming. If this therapist
has physically touched you in any way that feels inappropriate,
or suggested you meet outside of her office, file a complaint
with the Board of Psychology or the Board of Behavioral Sciences.

Q.
Hi Shari. I'm a Marriage & Family Therapist with a practice
in northern California.My problem is, I have difficulty
asking for money owed to me from clients. These are mostly people
who've seen me for a relatively short time and either failed to
show up for scheduled appointments, or cancelled without adequate
notice. A couple of them have bounced checks, and asked if they
could pay me "when they have it." My caring nature makes
me reluctant to press, even though my instincts
tell me they have the money. Mytherapist
has worked with me on addressing the feelings that
are triggered in these instances (and I think this is helpful),
but she hasn't actually helped me deal with the
problem. Asking clients to pay me what they owe is extremely
difficult; I want them to know that I care
and that this door is open, should they (one day) choose to return--but
lately, it's been tough making ends meet. I'm not even certain I
should approach this issue, but I'm torn! "Miss
Giving"

A.
As a therapist, it's common to have 'misgivings' about collecting
from clients. Frankly, I know veryfew professionals who've
successfully worked through this predicament, because of unresolvedentitlementissues (difficulty with receiving).
The same elements that drew you intothis
work, are the ones that presently keep you disempowered (and broke),
as you've likely been conditioned from early childhood to put everyone
else's needs before your own.Here's an
important question: If you're up against survival concerns(you can barely pay your rent/mortgage and you're wondering
where your next meal's coming from)how effective
do you think you can be for your clients?
OK, here's the solution: First, you should (always)
send clients home with a written statement of your policies at the
startof their treatment, and have them
signan intake form that clearlydetailsyour cancellation policy. To recover your money:
Begin by mailing a brief/straightforward letter, nicely
asking them to pay their "unpaid balance."Let
them know you're willing to set up a payment schedule if they cannot
affordto send you the entire amount, but give them a reasonable
deadline to respond with their first check. If a secondletter is necessary, let them know that while it's not your
preference, their debt will be turned over for collection if they
do not respond with a money order or cashier's check within
a deadline/dateof several weeks. If they're still
unresponsive to your request, find an attorney who's
willing to work for a debt-recovery fee of about 20 - 30% and put
him/her in charge of this matter. Your attorney's letters to these
clients should be professional, firm and not too wordy, and you
should look them over before they're sent. If debt collection
is your lawyer's primaryarea of specialization,
you may not need to be this involved, but make sure you're comfortable
with what's sent under his/her letterhead; remember, this person
represents you!Clients are usually
asked to send payments directly to his/her office. Your attorney
can send you photocopies of these checks and settle up with you
as the money arrives, or calculate his/her total fee at the end
of this process. Most people want toavoidjudgments
against their credit, or having to show up in small claims
court. These clients have treated you with careless disregard,
and there's undoubtedly a pattern of this with others as
well (how you do anything, is how you do everything). Will
they ever return? It's very unlikely.And
if they did, wouldn't your counter-transferenceget in
the way of your trusting them enough to treat them again?
Nobody can pay you to "care" about them(that either comes with the territory, or it doesn't),
but theymustpay
you for your time & expertise. In context of this,
you may find my article (link above) veryhelpful. Best
of luck!